Otolaryngology in Critical Care

Abstract

Diseases affecting the ear, nose, and throat are prevalent in intensive care settings and often require combined medical and surgical management. Upper airway occlusion can occur as a result of malignant tumor growth, allergic reactions, and bleeding events and may require close monitoring and interventions by intensivists, sometimes necessitating surgical management. With the increased prevalence of immunocompromised patients, aggressive infections of the head and neck likewise require prompt recognition and treatment. In addition, procedure-specific complications of major otolaryngologic procedures can be highly morbid, necessitating vigilant postoperative monitoring. For optimal outcomes, intensivists need a broad understanding of the pathophysiology and management of life-threatening otolaryngologic disease.

Keywords: Ludwig's angina; epiglotittis; epistaxis; laryngectomy; retropharyngeal abscess.

Figure 1.

Vascular anatomy of the nose. (A) Schematic shows the anatomic blood supply to the nose. (B) Ninety percent of nosebleeds originate from the anterior plexus of Kiesselbach and are controlled mostly by conservative measures, whereas 10% of nosebleeds are from posterior sources, such as the sphenopalatine artery, and can require packing, endoscopic hemostasis techniques, and rarely endovascular embolization of the bleeding vessel.

Figure 2.

Ludwig’s angina. (A) Sagittal computed tomographic (CT) scan of the neck shows a large, ill-defined region of hypodensity in the floor of the mouth/sublingual space (blue arrow) and diffuse fasciitis of the neck extending to involve the epiglottis and submandibular space. (B) Axial CT scan shows an abscess in the floor of the mouth (red arrow) and a right submandibular space abscess and soft tissue emphysema (yellow arrowhead). (C) Schematic diagram shows the sublingual and hypopharyngeal spaces involved in the infection, usually related to dental infection.

Figure 3.

Retropharyngeal abscess. Contrast-enhanced (A) axial and (B) sagittal computed tomographic scans of a retropharyngeal abscess show a huge prevertebral space abscess associated with extensive soft tissue swelling, mass effect, and rim enhancement (asterisks). (C) Anatomic schematic shows the corresponding space involved.

Figure 4.

Epiglottitis. Lateral radiographs of the neck show (A) normal-sized epiglottis and airway and (B) markedly swollen epiglottis and narrowed airway in the epiglottitis (blue arrows). (C) Sagittal computed tomographic scan of the neck shows folding of the epiglottis (white asterisk) and marked edema/thickening of the aryepiglottic fold, true and false cords (white arrow). These findings represent supraglottitis. (D) Schematic diagram shows the inflamed epiglottis in the context of the hypopharyngeal space.

Figure 5.

Tracheostomy versus laryngectomy. Anatomic comparison of airflow in the setting of (A) regular tracheostomy versus (B) through a stoma after total laryngectomy. Importantly, transoral or transnasal intubation of the trachea is impossible in patients who are status postlaryngectomy (B).